Provider Demographics
NPI:1689703191
Name:LIFEROOTS, INC
Entity Type:Organization
Organization Name:LIFEROOTS, INC
Other - Org Name:RCI, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:MARY
Authorized Official - Last Name:CATES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-255-5501
Mailing Address - Street 1:1111 MENAUL BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-1614
Mailing Address - Country:US
Mailing Address - Phone:505-255-5501
Mailing Address - Fax:505-255-9971
Practice Address - Street 1:1111 MENAUL BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-1614
Practice Address - Country:US
Practice Address - Phone:505-255-5501
Practice Address - Fax:505-255-9971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM01771248251S00000X
NMPENDING261QD1600X, 261QH0700X, 261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMD0886Medicaid